Friday, November 11, 2011

The scars from today's wars amount to a national pathology. America could take a generation to heal.

By James Kitfield

The troops come home from war much the way they left, largely invisible to a distracted nation. Returning units are typically met at an airfield by buses that shuttle them to a gated military base. On a parade ground, a commander reminds the assembled, some of the more than 2.3 million service members deployed during the past decade of war, of all that they accomplished. He recalls the brothers in arms who didn’t make it back and the memories that unite those who did. The shared hardships, the moments of terror and elation, the constant joking that held the awfulness at bay. The unbearable melancholy that descends at the playing of “Taps.”

The commander dismisses the formation, and the troops realize that the ties that bound their lives together are breaking. The married service members run into the open arms of their families, husbands holding babies they’ve never met, uniformed women hugging young children they can hardly recognize. Even before the smiles and tears subside, spouses sense the vast gulf that now lies between them and wonder how to get across. Single troopers head for the barracks, cracking wise but often wishing that they, too, had family to welcome them home. And, inevitably, there are the stragglers—young soldiers shuffling and chain-smoking, unsure of where to go or what to do next. Having come of age on distant battlefields, they are suddenly lost in America.

Even Col. David Sutherland, a decorated commander who served in Iraq, was shocked by the dizzying sense of alienation he felt on reentry. “Never in the history of our Republic have so few been asked to do so much for so long. And yet, when soldiers return home, they feel acutely this disconnect between the military and a civilian society that doesn’t even seem to be at war,” says Sutherland, the Joint Staff’s special assistant in charge of the Warrior and Family Support program. “We fall into the same trap of our fathers from World War II or Vietnam, which is to keep the memories of those sacred moments on the battlefield to ourselves. That’s how they become secrets, and secrets are not healthy.”

Tens of thousands of other troops return home on the aeromedical-evacuation flights that land routinely at Andrews Air Force Base in Maryland or Travis Air Force Base in California, where the buses waiting to meet them bear large red crosses. The critically wounded emerge from the massive C-17 transports first, nearly invisible beneath bandages, a jungle of medical equipment strapped to their gurneys. Next out are the less-dire cases, carried on stretchers. Finally, the ambulatory patients shuffle single file to the waiting buses. In the past decade, Air Mobility Command has flown more than 35,600 aeromedical-evacuation sorties, transporting more than 177,000 wounded or ill service members home.

Staff Sgt. Dan Nevins was one of those patients who landed on the tarmac at Andrews in 2005 clinging to life. Having already lost one leg, he fought through 18 months and 30 surgeries at Walter Reed Army Medical Center trying in vain to save the other. “In retrospect, finally letting go of my other leg and getting on with my life was the best decision I ever made,” says Nevins, who now works for the nonprofit Wounded Warrior Project helping other injured veterans try to get on with their lives.

Thousands of other troopers have returned home in flag-draped coffins at Dover Air Force Base in Delaware. Last month, President Obama and other senior officials traveled to Dover to honor the 30 American troops killed in Afghanistan on Aug. 6 after their helicopter was shot down, the worst single-day loss of the long Afghan war. Their names joined the honor roll of more than 6,000 fallen service members from Iraq and Afghanistan. The deafening silence of the dead continues to send shock waves through a landscape of grief inhabited by their families and comrades—the collateral wounded of these wars.

“A death in the military is unlike any other loss in our society, because there are so many complicating factors,” says Bonnie Carroll, founder and president of the Tragedy Assistance Program for Survivors, or TAPS, which reaches out to grieving military families with “peer professionals” who have social work degrees and have also lost loved ones in the military. Because deaths often happen on long combat deployments, Carroll says, grieving spouses sometimes trick themselves into thinking that a missing service member will still walk through the front door someday. Other times, the manner of death is so traumatic that families receive multiple sets of remains. “When a death is so horrific in nature, and the spouse hears about it repeatedly in the media or third-party accounts, they can create a memory that leads to their own post-traumatic stress disorder.”

The pathology of war

Every war leaves its imprint on those who fight it and on the national psyche. At the 10-year mark, the wounds and mental scar tissue from Afghanistan and Iraq have amassed into something like a pathology unique to these conflicts—one that will afflict this country for a generation.

Due largely to advances in combat medicine, rapid aeromedical evacuation, and body armor, the wars have proven to be the least lethal in modern U.S. history. According to Dr. Ronald Glasser, a Vietnam-era Army surgeon and the author of the recent book, Broken Bodies, Shattered Minds: A Medical Odyssey from Vietnam to Afghanistan, for every battlefield death, 16 service members survived their wounds. The ratio in Vietnam, he said, was 2.4 wounded for every death. In the Civil War, the ratio was less than 1-to-1, with few soldiers surviving battlefield wounds.

In his book, Glasser warns that the nation will face a moral and economic reckoning in caring for so many wounded veterans. “Because of body armor there have been relatively few of the penetrating chest wounds or abdominal injuries that caused so many battle deaths in past wars,” he tells National Journal. “But no one was really prepared for the number of seriously wounded survivors.” According to the Pentagon, 168,000 service members wounded or injured in these wars are graded “60 percent disabled” or higher, and the VA faces a 492,000-case backlog of disability claims. More than 508,000 veterans of today’s wars have already been treated at VA hospitals and clinics. The Congressional Budget Office estimates that the medical costs associated with today’s veterans could come to $40 billion to $55 billion over the next decade.

Just as the current wars have dragged on, with tactics and geography shifting over the years, the pathology of these wounds has also mutated over time. Early on in Afghanistan, for instance, small arms caused many injuries. A few years into the fighting in Iraq—as insurgent bombs got bigger and the armor on U.S. military vehicles got thicker—troops absorbed blast waves through their seats, causing a spike in spinal-cord injuries, concussions, and brain trauma. Over the last 18 months in Afghanistan, the profile has changed again.

“As Afghanistan has turned primarily into a war of dismounted infantry, our polytrauma wards have seen a huge influx of troopers with really massive injuries from absorbing blasts while on foot patrol, including multiple amputations, really severe brain injury, and the emotional wounds that go with all of that,” says Dr. Shane McNamee, the chief of physical medicine and rehabilitation at the VA’s Polytrauma Rehabilitation Center in Richmond, Va. “In the past five years, I can’t tell you how many times we have regeared to tailor our care delivery to subsequent waves of service members with different kinds of wounds.”

But improvised explosive devices, the enemy weapon of choice in both conflicts, have caused their signature wounds, creating more than 1,300 amputees, numerous burn victims, and unknown numbers who suffer from traumatic brain injury. According to the advocacy group Veterans for Common Sense, more than 190,000 troops have suffered a concussion or brain injury. There is also growing evidence of links between TBI and posttraumatic stress disorder. “They both injure similar areas of the brain and exhibit similar symptoms,” says McNamee. “The lines between them are pretty gray.” According to a 2008 Rand survey, one in five veterans of these wars—some 300,000 people—are suffering either from major depression or PTSD, while 320,000 have suffered concussions or TBI.

Those growing numbers are significant. By allowing the Vietnam War—and the physical and emotional trauma it caused—to recede from our national consciousness, America inherited an epidemic of veterans suffering from the attendant ills of PTSD. Today, the post-9/11 generation of volunteers faces the same risk. “When a lot of us Vietnam veterans returned from war, it took us a decade or even two before we would even talk about what happened, and we bottled up a lot of anger and hurt,” says Tom Mitchell, a state director for U.S. Vets, a nonprofit that works to get homeless veterans off the streets. “A lot of us are determined not to let that happen with this new generation of combat veterans from Iraq and Afghanistan.”

The volunteers

Today’s wars are the first extended conflicts to be fought not by draftees but by a relatively small cohort of volunteers. That partly explains why the pathologies specific to this war have been so hard to predict. Like previous generations, however, today’s veterans generally keep the toxic aftereffects of war to themselves; they are simply too painful to admit or confront.

The small size of the all-volunteer force, for instance, has necessitated multiple combat deployments with inadequate breaks in between, which mental-health experts believe greatly increases the propensity for PTSD and its effects: depression, drug abuse, failed marriages, and emotional distress. The Defense Department’s Task Force on Mental Health found in 2007 that 38 percent of all active-duty service members have reported psychological symptoms after their tours. In some months this year, the suicide rate for active-duty service members has exceeded combat deaths, and in April, the VA’s suicide-prevention hotline received more than 14,000 calls—the most ever recorded in a single month. Dr. Robert Petzel, the VA undersecretary of health, says that doctors have become expert at recognizing and treating PTSD. “It’s probably true that multiple combat deployments increase the likelihood of PTSD,” he warns, “though we don’t have adequate research to prove that yet.”

Today’s all-volunteer force is also older than its draft-era counterpart, with more married service members and a larger number of uniformed women (14.6 percent of the active-duty total). More than 220,000 women have served in Iraq and Afghanistan, meaning that they’ve borne a higher share of the burden than in past wars. After 9/11, the military divorce rate climbed from 2.6 percent per year in 2001 to 3.6 percent in 2010. And 7.8 percent of women in the military divorced in 2010. (Because the military does not track overall divorce rates, count as divorced those service members who remarry in a given year, or follow up on the divorce rate of military personnel a year or two after they leave service, many experts believe the Pentagon underestimates the actual rate of military divorce.) “Overall divorce rates in the military could climb to as high as 80 percent for first marriages, which would mean that service in the military is becoming a precursor for divorce,” says Leticia Dreiling, a Houston Vets Center marriage and family therapist.

According to the VA, about one in five female veterans, or 20 percent, have also tested positive for posttraumatic stress related to “military sexual trauma,” a catch-all category that includes everything from sexual harassment to rape. “I actually think the military sexual trauma among women is much higher than the official figures, because we find that a lot of women service members feel guilty even talking about it,” says Judith Broder, a clinical psychologist who started The Soldiers Project, which offers free mental-health counseling to returning veterans. “Women veterans often feel like it’s a betrayal of their unit to speak about sexual trauma, so they tend to carry that wound a long time in silence, which increases the likelihood that it will develop into combat-stress disorder.” Women are also the fastest growing subset of the homeless-veteran population in America, according to Broder. Some land on the streets with their children.

As a percentage of the overall deployed force, the National Guard and Reserves have also shouldered more of the burden in Afghanistan and Iraq than in wars past. Yet as citizen-soldiers, reservists are less prepared for the stresses of a long combat tour. Indeed, the Task Force on Mental Health found that 49 percent of National Guardsmen reported experiencing psychological troubles after their deployments.

With the wars now winding down, the Pentagon estimates that as many as 1 million service members are likely to leave active duty in the next five years. They will enter a struggling economy where the jobless rate for young (ages 18 to 24) male veterans of Iraq and Afghanistan was 21.9 percent last year, and where veterans make up an estimated 20 percent of the homeless population. Many experts believe that the nation is simply unprepared for that approaching army of suffering.

“There are combat wounds you can see, and others that are invisible until symptoms develop long after service members return home, and we’re seeing an increase in virtually all of the metrics that track them,” says clinical psychologist Barbara Van Dahlen, the founder and president of the nonprofit Give an Hour, which connects veterans to a network of 6,000 mental-health professionals for free treatment.

Despite improvements in the military and VA health care systems—and the cooperation of nearly 5,000 nonprofits that serve military personnel—Van Dahlen sees a population at severe risk. “We should have learned from Vietnam, because all you have to do is study the homeless population today to understand that an awful lot of those veterans never really made it all the way home,” she says. “If we don’t get ahead of the challenge, we will risk losing this generation of veterans.”

The odyssey

The odyssey begins on a day like any other, logging duty in a faraway and unfamiliar land. Dan Nevin’s began in Iraq in a Humvee that was bouncing down a dusty road outside the Sunni-insurgent stronghold of Falluja. Without warning, his vehicle struck a roadside bomb. In an instant, Nov. 10, 2004, became the day that changed his life forever. By the time Nevin arrived at the U.S. military hospital in Landstuhl, Germany, 12 hours later, he had already lost one leg. Eventually, he lost the other to a bone infection.

In 2004 and 2005, the insurgencies that would eventually drive Iraq to the brink of civil war grew; correspondingly, the number of critically wounded service members pouring into the military medical system spiked. Nevin had to wait a week to get space on one of the crowded medical flights from Germany, and when he arrived at Walter Reed Army Medical Center, the staff was nearly overwhelmed. The care “was absolutely world-class,” he says. But the caregivers “just couldn’t handle all of the wounded. Those guys worked day and night, but it was a constant battle to get appointments if you needed a modification to your prosthetic leg. And when you did get an appointment, you could wait hours.”

Leaders of the military health care system were also beginning to realize the complexity of providing life-saving and rehabilitative care for so many severely wounded troops. Nevin’s Reserve activation had forced him to take a major pay cut from his job selling pharmaceuticals in California. Because his wife couldn’t afford to leave her own job, he could only see her one weekend every six weeks or so, putting more strain on their marriage. Yet compared to some of the younger active-duty patients who were told they were too injured to continue serving—meaning forced separation from the only job and culture they had known as adults—he felt lucky. “As a reservist, I had a college degree, a good job, and a supportive family to go home to,” Nevin says. “Some of those young kids joined the military right out of high school, however, and they didn’t have any of that to fall back on. So they found every excuse imaginable not to be released from Walter Reed. I thought they were crazy at the time, but later I realized that those young guys barely into their 20s were paralyzed with fear about what came next.”

By 2007, the problems at Walter Reed exploded into a full-blown scandal when The Washington Post published a series of articles detailing neglect, overworked case managers, and shoddy infrastructure. The commander of Walter Reed and the secretary of the Army resigned. But the scandal helped show the Pentagon and VA that their understaffed and stovepiped medical facilities were still unprepared for the wounded and maimed patients often transitioning back and forth between their systems. For the Army, the result was the creation of the Warrior Transition Command. From the beginning, its mission was to protect subsequent waves of returning wounded soldiers from the paralyzing fears that haunted young troopers at Walter Reed—the notion that the military was abandoning them at their moment of greatest need.

Lt. Col. Danny Dudek, who now works for the Warrior Transition Command, realized how precarious he felt when his own odyssey began in 2007. While traveling north of Baghdad just three months earlier, a penetrating explosive hit his armored Stryker fighting vehicle. The blast killed the soldier next to him and caused a spinal-cord injury in Dudek that left him paralyzed below the knee. Within days, he had been through surgery at Walter Reed; within a few months, he was sent to the VA hospital in Seattle to recover near his family. The care was excellent, but Dudek felt bereft of the camaraderie and support structures that he had come to depend on in his unit and somewhat lost in the VA bureaucracy. “We overlooked all the other stuff that goes into being a soldier, like being able to rely on strong leadership, showing up for formation, knowing that our families are taken care of,” Dudek says. “I think the Army realized that we can’t just treat wounded soldiers like patients. We need to continue to treat them like soldiers, too.”

That epiphany led to the establishment in 2007 of 29 community-based Warrior Transition Units for all soldiers whose care requires at least six months of complex medical treatment. The units blend the efforts of a primary-care doctor, a nurse case manager, and a squad leader. Soldiers help shape their own comprehensive transition plans, which include career and employment goals; Soldier and Family Assistance Centers aid their family members.

Still, the challenges are so complex that even this well-intentioned program initially went awry in some places. Media investigations of various units showed conflicts between the medical and military staff, overcrowding, and an overreliance on medication. An Army Inspector General’s report issued in January estimated that up to a third of all soldiers in Warrior Transition Units last year were overmedicated, hooked on drugs, or abusing illegal substances.

The Army has investigated the charges but hasn’t backed away from the concept. “We did have some inexperienced leaders in Warrior Transition Units who didn’t fully understand the complexity of tailoring a treatment regime to each soldier, and some soldiers do feel that military drills get in the way of their recovery,” says Dudek, who commanded a transition unit in Seattle. “There were also some conflicts between nurse case managers and squad leaders. But with good leadership, that organizational friction usually gets quickly resolved.” He adds that “the last thing we need to do is come back wounded and just ‘take a knee.’ What I told my soldiers is that you have to fight to overcome the pain, the apathy, and the fear of an uncertain future. And for me and a lot of them, it is the hardest fight of our lives.”

Falling through the cracks

When Lance Cpl. Nancy Schiliro was medically discharged from the Marine Corps in 2005 after losing an eye in a mortar attack in Iraq, there was no long counseling session or transition unit. They hadn’t been created yet. One day she was living in the 24/7 bubble of life as a Marine—being told what to do, where to go, when to eat, and who to hang out with—and the next day she was home and that bubble had burst. The whole experience was so disorienting that, for six months, Schiliro didn’t even realize that she was suffering from PTSD. “I wasn’t sleeping. I jumped at loud noises. I basically stayed to myself and stopped interacting with people. I just wasn’t me,” she says. Finally, her brother’s father-in-law, himself a former Marine, called a friend at a local veterans’ center, who reached out. “It’s taken me awhile to learn how to manage my disease, and it’s gotten better,” she says. “But I don’t think I’ll ever be totally cured.”

Cases like Schiliro—veterans who need care but fall into the gap between military medical treatment and VA follow-on care—have driven reforms designed to make the transition more seamless. The Pentagon and the VA established a Joint Executive Council that issued 26 initiatives to standardize treatment and evaluation systems. For instance, military treatment facilities today typically don’t release a wounded service member until he or she has scheduled appointments in the Veterans Health Administration system. If requested, one of a hundred VA “transition patient advocates” will even travel with service members as they move from major military hospitals to VA hospitals closer to home. Anticipating demand, the VA also hired 7,000 mental-health officials in recent years, expanded suicide-prevention hotlines, and established caregiver programs that provide stipends and travel allowances for family members who care for seriously wounded veterans. “The departments of Defense and Veterans Affairs have gone from a relatively low-level of interaction in 2001 to a degree of cooperation that is historically unprecedented,” says Petzel, the VA health undersecretary.

For all of those advances, however, major problems persist. Despite the move to a joint disability evaluation process designed to streamline claims procedures, some veterans are still waiting up to 400 days for a decision on whether they will receive payments and at what levels, and a backlog of nearly 500,000 late claims have gone beyond the 125-day standard at the VA. Until disability payments begin, easing some of their financial burdens, wounded veterans are susceptible to alcohol or drug abuse—or worse—to alleviate their suffering. “I know that VA and DOD have big challenges,” Senate Veterans’ Affairs Committee Chairwoman Patty Murray, D-Wash., said at a hearing earlier this year. “But service members and veterans continue to take their own lives at an alarming rate. Wait times for benefits continue to drag on for an average of a year or far more.”

Another sign of trouble: Despite aggressive outreach, only about half of the Iraq and Afghanistan vets have even registered with the VA, meaning there is a vast at-risk population. “A chief lesson of Vietnam was that we need to get new veterans help as early as possible, before their lives spiral into crisis,” says Fern Taylor, supervisor of a clinic for returning veterans at a VA hospital in Houston. “Too often, our first contact with a veteran is in the emergency room, through the criminal-justice system, or on our suicide-prevention hotline.”

Kathy Molitor, the suicide-prevention coordinator at a VA post-deployment clinic in Houston, has no doubt that many vets need help. In 2007, the VA’s suicide hotline received 9, 400 calls, she says, and the next year, it jumped to 67,400. In 2009, it reached 119,000, and last year it was up to 135,000. Just listening to the calls for help can induce secondary traumatic stress: I feel like an animal, unfit for civilized society.… My husband only wants to hang out and drink and do drugs with his buddies.… I can’t talk to my wife because she might be infected with my disease.… My husband barks orders at our children like they were soldiers.… After watching my buddy blown to bits, I’m angry all the time.… Why does Daddy want to go back to war? … Our son is constantly cleaning his gun in his room alone, and we can’t get him to stop.… I’m not/she’s not/he’s not the same person anymore …

The essential message that Molitor and the other hotline therapists try to convey to callers is simple: War is hazardous to your mental health. “It’s really no surprise that these veterans have posttraumatic stress, because these are hard issues for humans to deal with on top of all of life’s other stresses and difficulties,” she says. “On the phone, we try and let them know that these are normal reactions to what are really abnormal experiences.”

Brothers under the bridge

On a recent sweltering day, Oskar Gonzalez-Yetzirah of the nonprofit U.S. Vets trolled beneath one of Houston’s countless highway overpasses, offering bottles of water to the ragged men and women gathered there. He had a simple question for any takers.

“You a vet?”

U.S. Vets is one of roughly 5,000 nonprofits nationwide that aid military personnel and veterans. In a sense, they are America’s catchers in the rye—the last line of help for veterans poised on the precipice of a cliff. The veterans whom Gonzalez-Yetzirah finds under the overpass have already hit rock bottom, joining some 3,500 homeless veterans in Houston and 150,000 nationwide. Almost all are jobless; many are substance abusers or mentally ill.

He tries to coax the vets into government or nonprofit assistance systems. U.S. Vets has a 72-bed facility in downtown Houston, but it is overbooked by 30 spaces. Gonzalez-Yetzirah and his boss would have to work the phones to find an open slot at another shelter. He knows that many veterans who suffer from PTSD would rather sleep outside than subject their frayed nerves to the chaos of a homeless shelter. He also knows from experience that if red tape keeps him from logging the veterans into the system before nightfall, they will almost surely slip through his fingers and disappear onto the streets again.

As a former Marine who served in Iraq, Gonzalez-Yetzirah himself has also struggled with PTSD and readjustment issues. In his first job back—waiting tables—he almost clocked his boss, a pimply 18-year-old, for ordering him around. That might have landed him in the Harris County Jail, where he runs group-therapy sessions for the 400 to 600 jailed vets being held there on any given day. He now sees a new wave of vets approaching the precipice, just one similar outburst away from joining their brothers in jail or under the bridge. “I run into a lot of [recently returned] veterans in my work who are not homeless yet, but they are at the stage of running from place to place, sleeping on a buddy’s couch, living paycheck to paycheck and barely making ends meet,” Gonzalez-Yetzirah says.

Many are married to young wives who have little education and are caring for babies, even as the veterans struggle against their PTSD to hold down jobs. They tend to follow a pattern, he says: Soon, their families will break apart and the vets will end up on the streets. “I’ve seen that enough times to understand how it happens. I just don’t understand how we as a country can allow those people who fought for our freedoms to stay homeless.”

Like previous generations of veterans before them, the post-9/11 volunteers are coming home from war burdened by wounds and sorrows. Only this time it’s not too late to help them carry that weight.

The soldiers sent to fight on our behalf are not victims; they don’t want our pity, and they have much to contribute and even to teach us. But combat veterans struggling to regain a sense of normalcy in everyday life need and deserve the same assurances at home that their buddies gave them on faraway battlefields: They need to know that someone has their back.

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